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USMLE Step 3 > Neurology > Flashcards

Flashcards in Neurology Deck (218):
1

- sudden onset weakness on ONE side of body
- weakness of half of face
- aphasia
- +/- partial/total loss of vision

stroke, or TIA (transient ischemic attack)

2

stroke SPARES what part of face?

UPPER THIRD OF FACE

(from the eyes up)

3

80% of strokes are

ischemic (d/t thrombosis, or embolism)

4

20% of strokes are

hemorrhagic

5

symptoms last

TIA (transient ischemic attack)

6

transient loss of vision in one eye

amaurosis fugax

7

TIAs are ALWAYS caused by what? and are NEVER caused by?

- emboli, or thrombosis

- never hemorrhage

8

best INITIAL test for stroke or TIA

head CT WITHOUT contrast

9

how many days are needed to achieve > 95% sensitivity in detection of nonhemorrhagic stroke?

3-5 days

10

achieves 99% sensitivity for nonhemorrhagic stroke w/i 24 hours

MRI

11

can be positive for nonhemorrhagic stroke w/i 1 hour

MRA

12

treatment for stroke w/i 3 HOURS of onset of symptoms

thrombolytics

13

ABSOLUTE CI to thrombolytic therapy in a stroke pt (8)

- h/o hemorrhagic stroke
- intracranial mass
- active bleeding/surgery w/i 6 weeks
- bleeding d/o
- CPR w/i 3 weeks
- suspicion of aortic dissection
- stroke w/i 1 year
- cerebral trauma/brain surgery w/i 6 months

14

best INITIAL treatment for pts coming too late for thrombolytics, and AFTER use of thrombolytics

aspirin

15

treatment if pt develops stroke while already on aspirin

- switch to clopidogrel, or
- add dipyridamole to aspirin

16

should be added to ALL nonhemorrhagic strokes

statin

17

arterial lesions and symptoms:

- C/L PROFOUND LOWER extremity weakness
- mild upper extremity weakness
- personality changes, or psychiatric disturbance
- urinary incontinence

anterior cerebral artery

18

arterial lesions and symptoms:

- C/L PROFOUND UPPER extremity weakness
- APHASIA (can't speak)
- apraxia/neglect (inability to carry out purposeful movements)
- eyes deviate TOWARDS the lesion
- C/L homonymous hemianopsia

middle cerebral artery

19

arterial lesions and symptoms:

- prosopagnosia (inability to recognize faces)

posterior cerebral artery

20

arterial lesions and symptoms:

- vertigo
- N/V
- "drop attack," LOC
- VERTICAL nystagmus
- dysarthria (difficulty pronouncing words), and dystonia
- sensory changes in face and scalp
- ATAXIA
- B/L FINDINGS

vertebrobasilar artery

21

arterial lesions and symptoms:

- I/L FACE
- C/L body
- VERTIGO
- Horner's syndrome (doesn't have to be all 4 signs: miosis, ptosis, anhydrosis, and enophthalmos)

posterior inferior CEREBELLAR artery

22

arterial lesions and symptoms:

- MUST BE AN ABSENCE OF CORTICAL DEFICITS
- ataxia
- Parkinsonian signs
- sensory deficits
- hemiparesis (most notable in face)
- possible bulbar signs (impairment of CNs 9, 10, 11, 12)

lacunar infarct

23

arterial lesions and symptoms:

- amaurosis fugax

ophthalmic artery

24

after initial treatment of stroke/TIA, most important issue is to?

determine origin of stroke

25

the following are indicated in ALL pts with stroke/TIA

- echocardiogram
- carotid dopplers/duplex
- EKG/Holter monitor

26

the following are indicated in young pts (

- ESR
- VDRL, or RPR
- ANA
- ds-DNA Ab
- protein C
- protein S
- factor V Leiden mutation
- antiphospholipid syndrome

27

the younger the pt, the more likely the cause of stroke is from

vasculitis, or hypercoagulable state

28

treatment for status epilepticus

benzodiazepine

29

treatment for status epilepticus if seizure PERSISTS after use of benzodiazepine

add fosphenytoin

30

treatment for status epilepticus if seizure PERSISTS after use of benzodiazepine, and fosphenytoin

add phenobarbital

31

treatment for status epilepticus if seizure PERSISTS after use of benzodiazepine, fosphenytoin, and phenobarbital

general anesthesia (pentobarbital, thiopental, midazolam, propofol)

32

the following tests should be ordered on a pt having a seizure

- sodium, calcium, magnesium, glucose, O2
- stat head CT (MRI if CT is negative)
- urine toxicology screening
- liver and renal function

33

if INITIAL tests do not reveal etiology of seizure, next step in mangement

EEG (electroencephalogram)

34

generally, should you treat with chronic antiepileptic drug therapy after a SINGLE seizure?

NO

35

treat seizures chronically under the following circumstances:

- strong family history
- abnormal EEG
- status epilepticus requiring a benzodiazepine
- non-correctable precipitating cause (brain tumor)

36

first-line treatments for long-term management of seizures

- valproic acid
- carbamazepine
- phenytoin
- levetiracetam
- lamotrigine

(all equal in efficacy)

37

adverse effect of lamotrigine

- Stevens-Johnson syndrome

38

second-line treatments for long-term management of seizures

- gabapentin
- phenobarbital

39

best treatment for absence seizures (petit mal)

ethosuximide

40

- tremulous pt w/ slow, abnormal "festinating" gait
- predominantly a gait d/o
- orthostasis

Parkinson's disease

41

PE findings of Parkinson's disease

- cogwheel rigidity
- resting tremor
- hypomimia (masklike/underreactive face)
- micrographia
- orthostasis
- INTACT cognition and memory

42

diagnostic test for Parkinson's disease

NONE, clinical diagnosis

43

treatment for Parkinson's disease:

- mild symptoms
- under age 60

anticholinergic agent (benztropine, hydroxyzine)

44

treatment for Parkinson's disease:

- mild symptoms
- over age 60

amantadine

45

treatment for Parkinson's disease:

- severe symptoms

- levodopa/carbidopa
- COMT inhibitors (tolCAPONE, entaCAPONE)
- MAO inhibitors (seleGILINE, rasaGILINE)

46

definition of severe symptoms in Parkinson's disease

inability to perform ADL

47

resting tremor

- diagnosis
- treatment

- Parkinson's disease
- amantadine

48

intention tremor

- diagnosis
- treatment

- cerebellar d/o
- treat etiology

49

resting AND intention tremor

- diagnosis
- treatment

- essential tremor
- propranolol

50

- abnormalities of ANY part of CNS
- optic neuritis
- MOTOR and SENSORY problems
- bladder defect
- fatigue
- hyperreflexia
- spasticity
- depression

multiple sclerosis

51

MC abnormality of multiple sclerosis

optic neuritis

52

best INITIAL test for multiple sclerosis

MRI

53

MOST ACCURATE test for multiple sclerosis

MRI

54

when is CSF tap indicated in multiple sclerosis?

if MRI is nondiagnostic

(check for presence of oligoclonal bands)

55

best INITIAL treatment for acute exacerbation of multiple sclerosis

steroids

56

disease-modifying treatment for multiple sclerosis

- beta interferon
- glatiramer
- mitoxantrone
- natalizumab
- fingolimod
- dalfampridine

57

adverse effect of natalizumab

PML

58

treatment for fatigue in multiple sclerosis

amantadine

59

treatment for spasticity in multiple sclerosis

- baclofen
- tizanidine

60

- slowly progressive loss of memory EXCLUSIVELY in older pts (> 65 yoa)
- NO focal deficits
- diagnosis of exclusion

Alzheimer's disease

61

for ALL pts w/ memory loss, you must order the following:

- head CT
- B12 level
- TSH/T4
- VDRL, or RPR

62

only abnormal test in Alzheimer's disease will be

head CT showing DIFFUSE, SYMMETRICAL ATROPHY

63

standard of care treatment for Alzheimer's disease

anticholinesterase inhibitors

- donepezil
- rivastigmine
- galantamine

64

- PERSONALITY and BEHAVIOR become abnormal FIRST
- memory loss afterwards

frontotemporal dementia (Pick's disease)

65

head CT, or MRI shows what in frontotemporal dementia (Pick's disease)?

FOCAL atrophy of FRONTAL and TEMPORAL lobes

66

treatment for frontotemporal dementia (Pick's disease)

same as Alzheimer's disease:

anticholinesterase inhibitors

- donepezil
- rivastigmine
- galantamine

67

- caused by prions
- RAPIDLY progressive dementia
- MYOCLONUS

Creutzfeldt-Jakob disease (CJD)

68

MOST ACCURATE test for Creutzfeldt-Jakob disease (CJD)

brain biopsy

69

CSF shows what in Creutzfeldt-Jakob disease (CJD)?

14-3-3 protein

(if found, spares pt from needing brain biopsy)

70

- Parkinson's disease PLUS dementia
- very vivid, detailed hallucinations

lewy body dementia

71

- wet: urinary incontinence
- weird: dementia
- wobbly: wide-based gait/ataxia

normal pressure hydrocephalus (NPH)

72

diagnostic tests for normal pressure hydrocephalus (NPH)

- head CT
- lumbar puncture showing NORMAL pressure

73

treatment for normal pressure hydrocephalus (NPH)

shunt placement

74

- young pt (30's)
- family history
- dementia
- psychiatric disturbance w/ personality changes
- chorea/movement d/o

huntington's disease/chorea

75

diagnosis for huntington's disease/chorea

genetic testing

(autosomal dominant)

76

treatment for movement d/o in huntington's disease/chorea

tetrabenazine

77

symptomatic control of huntington's disease/chorea

antipsychotics

78

what percentage of migraine headaches are unilateral vs bilateral?

- 60% U/L
- 40% B/L

79

triggers for migraines

- cheese
- caffeine
- menstruation
- OCPs

80

symptoms that may proceed migraine headache

- aura of bright flashing lights
- scotomata
- abnormal smells

81

when should head CT or MRI be done for migraines?

- sudden and/or severe
- onset of headaches AFTER age 40
- FNDs

82

best INITIAL (abortive) treatment for migraines

sumatriptan, or ergotamine

83

prophylactic treatment for migraines (requires several weeks to take effect)

- BB
- CCB
- TCA
- SSRI

84

when should a pt be placed on prophylactic treatment for migraines?

4 or more headaches per month

85

- 10x more frequent in men than women
- EXCLUSIVELY unilateral
- redness/tearing of eye
- rhinorrhea

cluster headache

86

best INITIAL (abortive) treatment for cluster headache

triptans, or 100% oxygen

87

best INITIAL prophylactic treatment for cluster headache

CCB

88

- tenderness of temporal area
- jaw claudication

temporal arteritis

89

diagnostic test for temporal arteritis

ESR

90

MOST ACCURATE test for temporal arteritis

temporal artery biopsy

91

most important treatment for temporal arteritis

STEROIDS

(a delay may result in permanent vision loss)

92

- obese, young woman w/ headache and double vision
- papilledema
- normal CT/MRI
- +/- vitamin A use
- 6th CN palsy
- pulsatile tinnitus

pseudotumor cerebri

93

MOST ACCURATE test for pseudotumor cerebri

LP w/ OPENING PRESSURE MEASUREMENT (markedly elevated)

94

treatment for pseudotumor cerebri

- weight loss
- acetazolamide
- surgery if those fail

95

- room spinning
- N/V
- HORIZONTAL nystagmus

vertigo

96

ALL pts w/ vertigo should have what?

MRI of internal auditory canal

97

causes of vertigo:

- changes w/ position
- NO hearing loss

benign positional vertigo (BPPV)

98

causes of vertigo:


- does NOT change w/ position
- NO hearing loss

vestibular neuritis

99

causes of vertigo:


- acute
- hearing loss

labyrinthitis

100

causes of vertigo:


- chronic
- hearing loss

Meniere's disease

101

causes of vertigo:

- ATAXIA
- hearing loss

acoustic neuroma

102

causes of vertigo:

- h/o trauma
- hearing loss

perilymph fistula

103

PE finding in BPPV

Dix-Hallpike maneuver

104

treatment for BPPV

meclizine

105

treatment for vestibular neuritis

meclizine

106

treatment for labyrinthitis

meclizine and steroids

107

treatment for Meniere's disease

salt restriction and diuretics

108

diagnosis for acoustic neuroma (8th CN tumor related to neurofibromatosis)

MRI of internal auditory canal

109

treatment for acoustic neuroma (8th CN tumor related to neurofibromatosis)

surgical resection

110

- h/o chronic heavy alcohol abuse
- confusion w/ confabulation
- ataxia
- memory loss
- gaze palsy/ophthalmoplegia
- nystagmus

Wernicke-Korsakoff syndrome

111

diagnostic tests for Wernicke-Korsakoff syndrome

- head CT
- B12 level
- TSH/T4
- VDRL, or RPR

112

treatment for Wernicke-Korsakoff syndrome

THIAMINE FIRST, then glucose

113

if a CNS infection is suspected, when should you do a head CT before doing an LP?

- h/o CNS disease
- FND
- PAPILLEDEMA
- seizures
- altered consciousness
- significant delay in ability to perform LP

114

if CNS infection is suspected, next steps in management

- LP
- blood cultures
- empiric antibiotics

115

does a negative blood culture exclude meningitis?

NO, only 50-60% sensitive

116

gram + diplococci

Pneumococcus

117

gram - diplococci

Neisseria

118

gram - pleomorphic, coccobacillary organisms

Haemophilus

119

gram + bacilli

Listeria

120

CSF glucose below 60 is consistent w/

bacterial meningitis

121

best INITIAL test for meningitis

CSF cell count

122

if thousands of neutrophils are present in CSF, next step in management

start IV ceftriaxone, vancomycin, and steroids

123

MOST IMPORTANT criterion to determine need to treat pt w/ suspected meningitis

CSF cell count

(thousands of neutrophils is meningitis until proven otherwise)

124

- HIV-positive pt w/ CD4 count

Cryptococcus

125

best INITIAL test for Cryptococcal meningitis

India ink

126

MOST ACCURATE test for Cryptococcal meningitis

Cryptococcal Ag

127

best INITIAL treatment for Cryptococcal meningitis

amphotericin and 5-flucytosine (5FC), followed by fluconazole PO until CD4 count is > 100

128

- recent camping/hiking trip
- tick exposure only remembered by 20% of pts
- joint pain
- 7th CN palsy
- rash w/ central clearing (target lesion)

lyme disease

129

MOST ACCURATE tests for CNS lyme disease

serology and Western blot of CSF

130

treatment for CNS lyme disease

IV ceftriaxone, or IV PCN

131

- camper/hiker
- rash that STARTS on WRISTS and ANKLES, and moves centripetally toward center
- fever, headache, and malaise PRECEDE rash
- only 60% will remember tick bite

rocky mountain spotted fever

132

- extremely difficult diagnosis
- look for immigrant w/ h/o lung TB
- presentation is very slow over weeks to months
- if case describes fever, headache, and neck stiffness over HOURS then it is not TB

TB meningitis

133

CSF protein level in TB meningitis

very high

134

acid fast stain is positive in what percentage of TB meningitis?

10%

135

treatment for TB meningitis

rifampin, isoniazid, pyrazinamide, ethambutol, and steroids

136

- diagnosis of exclusion
- lymphocytic pleocytosis (elevated WBCs)

viral meningitis

137

treatment for viral meningitis

no specific treatment

138

treatment for Listeria monocytogenes meningitis

IV ampicillin

139

- elderly pt
- neonatal pt
- HIV-positive pt
- asplenic pt
- immunocompromised w/ leukemia/lymphoma
- elevated neutrophils in CSF

Listeria monocytogenes meningitis

140

- adolescent pt
- pt in the military
- asplenic pt
- pt w/ TERMINAL COMPLEMENT DEFICIENCY

Neisseria meningitidis

141

treatment for Neisseria meningitidis meningitis

- respiratory isolation
- IV ceftriaxone

142

isolation type for Neisseria meningitidis meningitis

droplet precautions

143

Neisseria meningitidis meningitis: prophylactic treatment for close contacts

rifampin, ciprofloxacin, or ceftriaxone

144

fever + confusion over a few hours =

encephalitis

145

best INITIAL test for encephalitis

head CT scan

146

MOST ACCURATE test for encephalitis

PCR of CSF

147

best INITIAL treatment for encephalitis

acyclovir (MCC of encephalitis in USA is HSV)

148

treatment for acyclovir-resistant pts for encephalitis

foscarnet

149

- fever, headache, FND
- "ring," or contrast-enhancing lesion

brain abscess

150

next step in management of brain abscess is based on?

HIV status

151

if HIV-negative, next step in management of brain abscess

brain biopsy

152

if HIV-positive, next step in management of brain abscess

treat for toxoplasmosis w/ pyrimethamine/sulfadiazine x 2 weeks and repeat head CT

153

- NON-enhancing brain lesions in HIV-positive pt
- no mass effect

progressive multifocal leukoencephalopathy (PML)

154

treatment for progressive multifocal leukoencephalopathy (PML)

raise CD4 count w/ ART

155

- Mexican pt w/ seizure
- multiple 1cm CYSTIC lesions (calcify over time)

neurocysticercosis

156

diagnosis for neurocysticercosis

serology

157

treatment for neurocysticercosis if still active and uncalcified

albendazole and steroids

158

treatment for neurocysticercosis if there's only calcifications

antiepileptics only

159

head trauma and intracranial hemorrhage:

focal deficits: never
head CT: normal

concussion

160

head trauma and intracranial hemorrhage:

focal deficits: rarely
head CT: ecchymosis

contusion

161

head trauma and intracranial hemorrhage:

focal deficits: +/-
head CT: crescent-shaped collection

subdural hemorrhage

162

head trauma and intracranial hemorrhage:

focal deficits: +/-
head CT: lens-shaped collection

epidural hemorrhage

163

best initial test for head trauma and LOC

head CT scan

164

treatment for concussion

none

165

treatment for contusion

admit for observation

166

treatment for subdural and epidural hemorrhage

- leave small ones alone
- drain large ones

167

treatment for large intracranial hemorrhage w/ mass effect

- intubation/hyperventilation to decrease ICP (decrease pCO2 to 28-32 to constrict cerebral blood vessels)
- mannitol to decrease ICP
- surgical evacuation

168

which pts should receive stress ulcer prophylaxis

- head trauma
- burns
- endotracheal intubation w/ mechanical ventilation

169

- sudden, severe headache
- stiff neck
- photophobia
- LOC (in 50% of pts)
- FND (in 30% of pts)

subarachnoid hemorrhage (SAH)

170

best INITIAL test for subarachnoid hemorrhage (SAH)

head CT w/o contrast

171

MOST ACCURATE test for subarachnoid hemorrhage (SAH)

lumbar puncture

172

normal WBC to RBC ratio in CSF

1:500

173

treatment for subarachnoid hemorrhage (SAH)

- angiography to locate site of bleeding
- embolize site of bleeding (superior to surgical clipping)

174

treatment for subarachnoid hemorrhage (SAH) if hydrocephalus develops

ventriculoperitoneal shunt (VP shunt)

175

treatment to prevent stroke in subarachnoid hemorrhage (SAH)

nimodipine (CCB)

176

50% chance of what if pt rebleeds in SAH?

pt will die

177

spine d/o's:

nontender

lumbosacral strain

178

spine d/o's:

tender

cord compression

179

spine d/o's:

tender and fever

epidural abscess

180

spine d/o's:

pain on walking downhill

spinal stenosis

181

- defective fluid cavity in center of spinal cord caused by trauma, tumor, or congenital defect
- loss of sensation of pain and temperature in UE's B/L in cape-like distribution over neck, shoulders, and down both arms

syringomyelia

182

diagnosis of syringomyelia

MRI

183

treatment for syringomyelia

surgery

184

diagnosis of cord compression

MRI

185

MOST ACCURATE test for cord compression if diagnosis is unclear from history

biopsy

186

MOST URGENT step in cases of cord compression

steroids to reduce swelling

187

diagnosis of spinal epidural abscess

MRI

188

treatment for spinal epidural abscess

treat against Staphylococcus

- oxacillin
- nafcillin

189

treatment for spinal epidural abscess w/ large accumulations

surgical decompression

190

diagnosis of spinal stenosis

MRI

191

treatment for spinal stenosis

surgical decompression

192

- ALL SENSATION is lost except position and vibratory sense

anterior spinal artery infarction

193

treatment for anterior spinal artery infarction

no specific treatment

194

- traumatic injury to spine (e.g. knife wound)
- loss of I/L position and vibratory sense
- loss of C/L pain and temperature

Brown-Sequard syndrome

195

idiopathic d/o of BOTH upper and lower motor neurons

- upper motor neuron signs:
= hyperreflexia
= + Babinski
= spasticity
= weakness

- lower motor neuron signs:
= wasting
= fasciculations
= weakness

amyotrophic lateral sclerosis (ALS)

196

treatment for amyotrophic lateral sclerosis (ALS)

riluzole (blocks glutamate accumulation)

197

MCC of peripheral neuropathy

DM

198

treatment for peripheral neuropathy

gabapentin, or pregabalin

199

- pain and weakness of 1st 3 digits of hand
- symptoms worsen w/ repetitive use

carpal tunnel syndrome

200

treatment for carpal tunnel syndrome

- splint
- steroids

201

- results from falling asleep w/ pressure on arms underneath body, or
- outstretched arm, draped over back of chair
- WRIST DROP

radial nerve palsy

202

- results from high boot pressing on back of knee
- FOOT DROP, and inability to Evert foot

peroneal nerve palsy

203

- hemifacial paralysis of BOTH UPPER and lower halves of face
- loss of taste on ANTERIOR 2/3 of tongue
- hyperacusis
- inability to close eye at night

7th cranial nerve palsy (Bell's palsy)

204

treatment for 7th cranial nerve palsy (Bell's palsy)

steroids

205

- occurs in pt w/ previous injury to extremity
- light touch results in extreme pain ("burning")

reflex sympathetic dystrophy

206

treatment for reflex sympathetic dystrophy

- NSAIDs
- gabapentin
- nerve block

207

- bed partner c/o pain and bruises in legs
- pt experiences uncomfortable feeling in legs relieved by movement
- associated w/ iron deficiency

restless leg syndrome (RLS)

208

treatment for restless leg syndrome (RLS)

pramipexole, or ropinirole

209

- ASCENDING weakness
- LOSS OF DTRs
- URI 2-4 weeks may precede
- paresthesia is common, but true sensory deficits are rare

Guillain-Barre syndrome

210

MOST URGENT step in Guillain-Barre syndrome

peak inspiratory pressure

211

most important factor in determining need for therapy w/ either IVIG, or plasmapheresis

peak inspiratory pressure

212

- weakness in muscles of mastication
- blurry vision d/t diplopia
- drooping of eyelids as day progresses

myasthenia gravis

213

best INITIAL test for myasthenia gravis

anti-acetylcholine receptor Abs (ACHR Abs)

214

MOST ACCURATE test for myasthenia gravis

clinical presentation AND ACHR Abs

215

best INITIAL treatment for myasthenia gravis

pyridostigmine, or neostigmine

216

treatment for myasthenia gravis in pts

thymectomy

217

treatment for myasthenia gravis if thymectomy does NOT work, or no response to pyridostigmine, or neostigmine

steroids

218

treatment for myasthenia gravis to keep pts off of long-term steroids

azathioprine, or cyclosporine